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Content ArticlePrevious research has shown that visitors can decrease the risk of patient harm; however, the potential to increase the risk of patient harm has been understudied. Sanchez et al. queried the Pennsylvania Patient Safety Reporting System database to identify event reports that described visitor behaviours contributing to either a decreased or increased risk of patient harm. The study provides insight into which visitor behaviours are contributing to a decreased risk of patient harm and adds to the literature by identifying behaviours that can increase the risk of patient harm, across multiple event types.
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Content ArticleRepresentatives from Mesh Ireland and Mesh Survivors have this week appeared before the Oireachtas Health Committee, where questions were raised about access to vital diagnostic machines and treament for women who have had vaginal mesh implants put in. Vaginal mesh devices were used to treat issues in women after childbirth, or in their later years, and while it’s not known how many procedures were carried out, it’s believed there were more than 10,000 on the public system alone. Women have experienced painful complications as a result of the procedure and Founder of the Mesh Survivors Ireland Campaign, Melanie Power, who’s a solicitor from Meelick, says many women are unable to work and can’t afford the cost of ongoing treatment. She believes questions need to be answered on why women affected by a post-natal procedure which can cause chronic pain are being means tested for the medical card. Listen to the full interview on Clare FM below.
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Content ArticleOver the past year, delays in transferring patients from an ambulance to a hospital have risen exponentially. In April 2022 there were over 41,000 delays of over 60 minutes, up over a staggering 450 per cent in 12 months. This equates to 71,000 hours lost, with a significant risk of harm to patients, even though the proportion being taken to hospital by ambulance has fallen thanks to successful initiatives such as “hear and treat” and “see and treat”. These delays mean that, too often, ambulance crews are not able to respond to 999 calls from critically ill patients. Instead they are being held in “stacks” of hundreds each day – as ambulance control room teams strive to prioritise overstretched resources. The current reality is that crews are often waiting with patients in hospital corridors or outside, hearing urgent calls to which they are unable to respond. In addition to the direct impact on patients, this is incredibly demoralising, even traumatising, for many staff involved. So why is this happening? In an article for the Independent, Daren Mochrie, chair of AACE – the Association of Ambulance Chief Executives, and Saffron Cordrey, interim chief executive at NHS Provider, discusses what is happening in the NHS.
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Extravasation: a patient safety priority
Patient Safety Learning posted an article in Extravasation
Extravasation injuries occur when some intravenous drugs leak outside the vein into the surrounding tissue causing trauma. This leaflet describes the risks posed by extravasation to patients, the extent of the problem in the NHS and what is currently being done to reduce the risk of avoidable harm. The leaflet sets out the action to prevent, recognise, treat and report extravasation which is urgently needed. It emphasises the importance of all suspected extravasation injuries being reported and investigated, with reviews undertaken to learn and take action to prevent harm to future patients. -
Content ArticleThis article highlights two written questions tabled in the House of Commons relating to recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review concerning surgical mesh implants.
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We’re looking for patients to help raise awareness of the damaging impact that surgical infections can have on people, and guide improvements. Have you ever been in surgery and contracted an infection? Do you want to share your experience anonymously and help create change? Take part in this survey: Experiences of Surgical Infections -
Content ArticleNever Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers are following national guidance and safety recommendations. In this blog John Tingle, a lecturer at Birmingham Law School, raises concerns about the number of Never Events that continue to take place within health services, the lack of public awareness about Never Events and the need to develop a safety culture that allows learning from Never Events to actually take place.
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Content ArticleThis editorial in BMJ Quality & Safety looks at the risks to patient safety posed by negative interpersonal interactions between healthcare professionals. The authors review a recent study on the subject by Linda Guo et al that revealed how and when these negative behaviours from staff may have an impact on patient outcomes and clinical performance. They highlight the huge scale of the impact of unacceptable behaviours, arguing that it is even greater than evidenced in Guo et al's research. They also highlight that there are other, largely unexplored impacts on healthcare workers, patients and their families when they are exposed to unacceptable interactions.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation explores medicines omission among patients with learning disabilities who are cared for in medium and low secure wards in mental health hospitals. A medicine omission is when a patient doesn't receive medicines that have been prescribed to them, and the investigation focused on a number of factors that could contribute to omission: the environment in which medicines administration takes place the availability and use of learning disability nurses in these environments the skills required for nurses to help patients with learning disabilities be involved in choices about their medicines. For it's reference event, the investigation looked at the case of Luke, who was detained in a medium secure ward of a mental health hospital. He spent 21 months on the ward before moving into a low secure ward at the same hospital, where he stayed for a further 11 months. Both wards were specifically designated for patients with learning disabilities. While at the hospital, there were a number of periods when Luke was not given the physical health medication he had been prescribed for his diabetes and high cholesterol. Although Luke’s medication record regularly noted that Luke refused the medication, Luke and his Mother disagreed with this version of events, stating that other factors led to Luke’s medicine omissions.
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Content ArticleMesh complications are rare and in most cases relatively minor. However, in a small number of cases they can be serious. These include mesh erosion/extrusion (when the mesh pokes through the vaginal wall or cuts through internal tissue), vaginal scarring, fistula formation, painful sex, bladder infection or perforation (piercing), bowel and nerve trauma and pelvic, back and leg pains. Some of these complications may occur years after surgery and can be difficult to treat. Serious complications are rare, given the tens of thousands of women who have had the implants, but can be life-changing for some women. As a result of concerns raised by mesh-affected women, in April 2018 the then Secretary of State for Health and Social Care, Jeremy Hunt MP, announced a review into the use of vaginal mesh. The review was led by Baroness Julia Cumberlege and recommendations made in the report of the Independent Medicines and Medical Devices Safety (IMMDS) “First Do No Harm”. The Government published its response to the IMMDS Review in July 2021.
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Content ArticleA restorative just culture has become a core aspiration for many organisations in healthcare and elsewhere. Whereas ‘just culture’ is the topic of some residual conceptual debate (e.g. retributive policies organised around rules, violations and consequences are ‘sold’ as just culture), the evidence base on, and business case for, restorative practice has been growing and is generating increasing, global interest. In the wake of an incident, restorative practices ask who are impacted, what their needs are and whose obligation it is to meet those needs. Restorative practices aim to involve participants from the entire community in the resolution and repair of harms. This book from Sidney Dekker, Amanda Oates and Joseph Rafferty offers organisation leaders and stakeholders a practical guide to the experiences of implementing and evaluating restorative practices and creating a sustainable just, restorative culture. It contains the perspectives from leaders, theoreticians, regulators, employees and patient representatives.
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Content ArticleThe use of pelvic mesh was paused in the UK in 2018 after some patients developed complications and severe pain following the treatment. In this report for CNA, a Singapore-based news channel, Kath Sansom, founder of campaign group Sling The Mesh, talks about the severe pain and life-changing side effects she experienced after pelvic mesh surgery. The report highlights the risks associated with mesh removal surgery, the fact that women harmed by mesh have been dismissed and ignored by the healthcare system, and concerns that the number of patients who experience complications from pelvic mesh has been underestimated. It also outlines the need for stronger medical device regulation in the UK, and looks at issues with compensation and redress for patients harmed by mesh.
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Content ArticleThis review, published in official journal of the International Society of Pharmacovigilance, Drug Safety, is aimed at determining the overall incidence, severity and preventability of medication-related hospital admissions in Australia. In its conclusions, the authors estimate that 250,000 hospital admissions in Australia are medication-related, with an annual cost of AUD$1.4 billion to the healthcare system, and that two-thirds of medication-related hospital admissions are potentially preventable.
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Content ArticleEmergency Department (ED) patient waiting times provide an important barometer for the wider pressures experienced in the NHS. There are currently alarming levels of crowding in our EDs, indicating that the health service is unable to meet the needs of patients with the current level of resource and capacity. In March 2022, for the first time in the history of the metric, the numbers of patients waiting 12-hours or more from decision to admit (DTA) exceeded 20,000. However the Royal College of Emergency Medicine (RCEM) argue that this number represents the tip of iceberg, as far greater numbers of patients experience extreme waits of 12 hours or more from their time of arrival. To investigate this issue further, RCEM carried out a Freedom of Information (FOI) request examining the extent of very long stays in EDs, with a particular focus on the numbers of patients waiting 12 hours or more from their time of arrival. They found that the current 12-hour data is a gross underrepresentation of the reality of patient waits, as it fails to capture the vast majority of patients who have no choice but to spend extended lengths of time in EDs. It additionally conceals the patients who are discharged home after very long stays.
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Content ArticleThis ITV documentary tells the story of how surgeon Ian Paterson duped his patients into believing they had cancer and performed unnecessary surgeries on them, before he was caught and jailed for 20 years in 2017. It features personal accounts of patients who were harmed by Paterson while he worked in NHS and private practice. Further reading: Report of the independent Inquiry into the issues raised by Paterson (4 February 2020) Patient Safety Learning’s response to the Paterson Inquiry (11 February 2020) Government response to the independent inquiry report into the issues raised by former surgeon Ian Paterson (16 December 2021)
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Content ArticleIn 2020, the Independent Medicines and Medical Devices Safety (IMMDS) Review made specific recommendations that the government provide justice and redress to thousands of women who have been harmed by surgical mesh implants. Surgical mesh, also known as transvaginal tape, is a medical device surgically implanted to support organs and tissue. It is primarily used to treat urinary incontinence in women, but is also used to treat hernias and to reinforce abdominal areas where women have had tissue removed to reconstruct their breasts after mastectomy. In this article for the Mail Online, John Naish highlights that two years after the IMMDS, none of its recommendations have been implemented properly and surgical mesh is still being used. He examines the case of Kelly Cook, a 37 year-old mother who has been left with constant pain, nerve issues and incontinence after mesh surgery in 2018. In spite of the impact the mesh is having on her life, she has been told she may not be seen at one of the new specialist mesh centres for two years due to the length of the waiting list. The article also highlights the fact that no financial redress has yet been offered to mesh victims, that women's pain is still not being seen as a serious issue, and that there is a concerning lack of research into the safety of mesh devices.
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Content ArticlePresentation from Peter Walsh, CEO of Action against Medical Accidents (AvMA), on a 'Harmed Patient Pathway' launched jointly by AvMA and the Harmed Patient Alliance in February 2021.
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Content ArticleIn this Editorial for the journal Midwifery, maternity experts come together to respond to the Ockenden review and discuss what went wrong and what needs to happen now.
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Content ArticleSurgeons' News is a magazine for surgical, dental and allied healthcare professionals. Published quarterly by the Royal College of Surgeons of Edinburgh, it features comment and opinion from leading professionals, plus reviews and reports on subjects relevant to all career levels. In an article in the June issue (page 16), Patient Safety Learning's Helen Hughes describes the steps being taken to address the widescale issue of avoidable harm.
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Content ArticleThis study, published in the Journal of the Royal Society of Medicine, examines national policies of complaint handling in English hospitals, how they are understood by those responsible for enacting them, and explores if there are any discrepancies between policies-as-intended and their reality in local practice.
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Content ArticleThis is an Early Day Motion tabled in the House of Commons on 18 May 2022, which calls on the Government to implement the recommendations of the Independent Medicines and Medical Devices Safety Review in full, including paying compensation to people disabled by sodium valproate.
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Content ArticleThe MHRA continues to receive serious reports of harm associated with insulin leakage for the NovoRapid PumpCart prefilled insulin cartridge in the Accu-Chek Insight Insulin pump. In some patients, there were serious consequences arising from inadequate supply of insulin, including diabetic ketoacidosis (DKA). Although the manufacturer Roche Diabetes Care (RDC) has implemented a number of risk minimisation strategies to reduce the incidence of these events, the impact of these is inconclusive and we are taking further action to protect patients. To protect patient safety, diabetes healthcare professionals should inform patients who use the Accu-Chek Insight of the risk of leakage. Clinical care decisions should be made to ensure patients are moved onto alternative pumps where possible.
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Content ArticleJeremy Hunt', former health secretary, has written a new book: 'Zero: Eliminating Preventable Harm and Tragedy in the NHS'. You can’t fault the former health secretary proposals for improving patient care, but his slick prose fails to acknowledge the damage inflicted on the NHS by his party during his tenure as health secretary writes Rachel Clarke, a palliative care doctor.
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Content ArticleSystemic racism in maternity care is an urgent human rights issue. For too long, evidence and narratives about why racial inequities in maternal outcomes persist have focussed on Black and Brown bodies being the problem – ‘defective’, ‘other’, a risk to be managed. Birthrights’ year-long inquiry into racial injustice has heard testimony from women, birthing people, healthcare professionals and lawyers outlining how systemic racism within maternity care – from individual interactions and workforce culture through to curriculums and policies – can have a deep and devastating impact on basic rights in childbirth. This jeopardises Black and Brown women and birthing people’s safety, dignity, choice, autonomy, and equality. The inquiry’s report, Systemic Racism, Not Broken Bodies, uncovers the stories behind the statistics and demonstrates that it is racism, not broken bodies, that is at the root of many inequities in maternity outcomes and experiences.
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Content ArticleOne box of chemicals mistaken for another. Ingredients intended to be life-sustaining are instead life-taking. Families in shock, healthcare providers reeling and fingers starting to point. A large healthcare system’s reputation hangs in the balance while decisions need to be made, quickly. More questions than answers. People have to be held accountable – does this mean they get fired? Should the media and therefore the public be informed? What are family members and the providers involved feeling? When the dust settles, will remaining patients be more safe or less safe? In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put them back together again. Building on the writings and wisdom of James Reason and other experts, the book explores new ways of thinking about Just Culture, and what this would mean for patients and family members, in addition to healthcare providers. With afterwords by two of the major players in this story, the authors make a compelling case that Just Culture is as much about fairness and healing as it is about supporting a safety culture.
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